POSTryRAD. MED. LYMPHOGRAPHY ANDTHE

POSTryRAD. MED. J. (1965), 41, 452

LYMPHOGRAPHY AND THE UROLOGIST

R. G. MAHAFFY, F.R.C.S.E., F.F.R.Department of Diagnostic Radiology, Royal Infirmary, Edinburgh.*

VARIOUS radiological methods of demonstratinglymph vessels and nodes have been utilised inthe past. Interstitial injection of thorotrast(Menville and Ane, 1932), and contrast in-jection into lymph nodes (Bruun and Engeset,1956), into body cavities (Bennet and Shivas,1954) and into joint spaces have all resultedin some degree of visualisation of a limitedsegment of the lymphatic system. Detailed studyof the pelvic and abdominal lymph nodes,however, was not possible until Kinmonth(1952) described a practical method of intralym-phatic injection. He used a water solublecontrast medium to demonstrate the lymphvessels of the legs in cases of lymphoedema.Such media, however, rapidly diffuse out ofthe lymphatics and for this reason are notsuitable for investigation of retroperitoneallymph nodes. Oily media are necessary for thispurpose and have become standard forlymphography (Wallace, Jackson, Schaffer,Gould, Greening, Weiss and Kramer, 1961;Ruttimann and Del Buono, 1962).

TechniqueThe technique of lymphography is now well

known and requires no detailed description.Briefly, lymphatics on the dorsum of the footare rendered visible by a subcutaneous injectionof a dye such as patent blue violet. Under localanx,sthesia a vessel is exposed and, by proximalobstruction and manipulation of the toes,distended to its maximum diameter. The vesselmay then be catheterised or a needle introduced.I have found catheterisation to be simpler andmuch more stable, allowing fairly free move-ment of the foot during the injection. A minuteincision is made in the vessel, a polythenecatheter (No. 45, Portland Plastics) introduced,the vessel ligated round the catheter and thecatheter sutured to the skin edge. For visual-isation of retroperitoneal nodes the proceduremust be repeated on the other foot. Warmedultra-fluid lipiodol is then injected bilaterally,simultaneously, at a very slow speed. I havefound 7-8 ml. lipiodol in each leg to be

*Present Address:X-ray Department, Royal Infirmary, A berdeen.

adequate in most cases, unless visualisation ofthe thoracic duct is required when largeramounts will be necessary. The procedureshould be controlled by means of an imageintensifier and the injection stopped if anyevidence of lymphatic obstruction is seen.At the termination of the injection a series offilms of the pelvic and lumbar regions is taken.These must include oblique and lateral viewsin order to throw the vessels off the underlyingbone and avoid superimposition of lymphaticstructures. In this series the lymph vessels arewell shown but the nodes are only partiallyfilled with contrast. It is noteworthy thatinitially the lipiodol will flow from afferent toefferent lymphatics, via the marginal sinus ofthe node, with no filling whatever of theremaining nodal sinuses. 24 hours later theseries is repeated, when the nodes should bewell filled with contrast and the vessels entirelyempty. Multiple projections are important atthis time to show all surfaces of the nodes.

Lipiodol remains in the nodes for 4-6 monthsand subsequent changes can be followed onplain films.

Lymphatic AnatomyOne of the major contributions of lympho-

graphy has been the demonstration of normallymphatic anatomy (Herman, Benninghoff,Nelson and Mellins, 1963). Two systems oflymphatics occur in the leg, one accompanyingthe long saphenous vein and the other theshort. Injection of a long saphenous lymphaticat the foot results in visualisation of up to20 vessels in the thigh, which drain intosuperficial inguinal lymph nodes. Shortsaphenous lymphatics drain into a separategroup of superficial inguinal nodes, and thereappears to be no communication between thesesystems in the leg (Jacobsson and Johansson,1959). About a dozen nodes are seen in thesuperficial inguinal region and these arearranged in a rather haphazard manner,although two groups can be recognised, onelying transversely below the inguinal ligamentand the other distal to this and parallel to thelong axis of the limb.

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454 POSTGRADUATE MEDICAL JOURNAL Au2ust. 1965

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FIG. 2.-Lateral pelvis film showing the medial external iliac lymphatic chain dipping deeplyinto the pelvis, particularly in the internal iliac region.

The external iliac system is divided into threechains. A lateral chain lies lateral to theexternal iliac artery, *a middle one medial tothe artery and a medial chain behind the veinon the lateral pelvic wall (Fig. 1). In a lateralview the medial chain can be seen to dip deeplyinto the pelvis (Fig. 2). The superficial in-guinal nodes drain partly directly to the lateraland middle chains and partly via one or twodeep inguinal nodes to the medial chain. Atthe distal ends of these chains lie the lateral,middle and medial retrocrural nodes, whichare fairly large and constant. There is a veryfree communication between the chains bymeans of multiple, transversely arranged vessels.Proximal to the medial retrocrural node liesthe 'middle' or 'principle' node which is largeand constant and communicates with theobturator nodes, which as a rule are filled bylymphography carried out from the foot.Owing to the valved nature of lymph vessels

retrograde flow does not normally occur. Asa result the internal iliac system is not filled

in its entirety although a few nodes are oftenseen, particularly in the lateral sacral group(Herman, Benninghoff, Nelson and Mellins,1963).The three external iliac chains continue into

the common iliac region, but there is a tendencyfor the medial and middle chains to unite,so that frequently only two chains are seenin this region, one anterolateral to the veinand one posteromedial. The medial chains ofboth sides form the nodes of the promontory.The close relationship of the nodes to the pelvicveins is the basis of pelvic venography as adiagnostic procedure, although I have foundsurprising enlargement of these nodes to bepossible without producing any venographic.abnormality (Mahaffy, 1964). In the commorkand internal iliac regions the ureter is seen tocome into intimate relationship with lymphnodes, enlargement of which may give rise toureteric obstruction or displacement '(Fig. 3).The common iliac lymphatics drain into a

plexus which virtually surrounds the vena cava

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MAHAFFY: Lymphography and the Urologist

FIG. 3.-Oblique film of the pelvis showing therelationship of the ureter to the pelvic lymphnodes.

and aorta and is divided into four groups.The right latero-aortic group lies on all sidesof the vena cava, but only one or two nodesare anterior to it and these occur only at itslower end. The left latero-aortic, pre-andretro-aortic groups lie to the left, in front ofand behind the aorta. Good ifilling of con-tralateral para-aortic lymphatics is normallyobtained when unilateral lymphography iscarried out, and an almost constant crossingvessel is seen at the first sacral level. At thelevel of the second lumbar vertebra the para-aortic vessels drain into the cisterna chyli andif sufficient contrast is injected the entirethoracic duct may be visualised. Only rarelyare mediastinal nodes demonstrated but leftsupraclavicular nodes are frequently seen. Byobstructing the termination of the thoracic ductby means of pressure in the left supraclavicularfossa, Seitzman and Halaby (1964) were ableto fill axillary and mediastinal nodes.

Extensive collateral pathways exist which arenot visualised, and possibly not utilised, unlesslymphatic obstruction is present. Such channelsmay give rise to metastatic deposits in bizarresituations, particularly where the main lymphpathways are obstructed by tumour.

Complications and PrecautionsA number of patients suffer from a mild

fever for 24-48 hours following lymphography.These patients are generally symptom-free andrecover spontaneously. In a small number ofcases, however, serious reactions have occuredand Desprez-Curely, Bismuth, Laugier andDescamps (1962) report one fatality. Manypatients have visible lipiodol in the lung-fieldsfollowing the injection and, although I havenot found reactions to be proportional to thedegree of pulmonary lipiodol embolism, never-theless it must be advisable to limit the amountof contrast reaching the blood stream. For thisreason the volume of contrast injected shouldbe restricted to the minimum consistent withgood radiographic detail of the lymphaticsystem. I stop the injection when the contrastreaches the mid-lumbar region, since I findthat subsequently good filling of the upperlumbar nodes occurs by onward passage oflipiodol in the vessels at the end of the injection,and that only minimal amounts pass beyondthe diaphragm.

It is also necessary to follow the course ofthe lipiodol so that lymphatic obstruction at anylevel may be recognised at an early stage. Ifevidence of this is seen the injection must bestopped since lymphatic-venous communicationsmay open up distal to such an obstruction,allowing lipiodol to pass directly into the bloodstream (Bron, Baum and Abrams, 1963).

It is necessary to X-ray the chest prior tolymphography and restrict the procedure tothose patients whose lung-fields are clear, sincepulmonary pathology of any kind tends toincrease the effect of lipiodol embolism.

Following radiotherapy to the abdomen orpelvis there is a reduction in the number andsize of lymph nodes, and these retain lesscontrast than normal, allowing larger amountsto pass beyond the diaphragm and enter theblood stream. Caution is necessary in thesepatients, therefore, and the volume injectedshould be reduced.

Lipiodol gives rise to a lipogranulomatousreaction in the nodes, characterised by largegiant cells. These reactions reach their peakin 2-3 days but thereafter subside and the nodefinally returns to normal. No fibrotic or otherpermanent change occurs in the node andrepeat lymphograms will demonstrate noevidence of lymphatic obstruction or otherabnormality attributable to the initial lympho-gram.

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POSTGRADUATE MEDICAL JOURNAL

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FIG. 4.-{A) Excised lymph node following lymphography. Note the two clearly definedcentral filling defects due to areas of fatty degeneration. '(B) Superficial inguinal lymphnode showing ill-defined defect at the proximal pole, due to the hilum. I(C) Excised groupof small nodes. A clearly defined, triangular filling defect is formed by the superimposedmargins of the nodes. (D) Superficial inguinal lymph node showing two ill-defined fillingdefects due to recurrent inflammatory changes.

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The Pathological NodeFollowing lymphography the normal lymph

node shows an even distribution of contrastdroplets throughout the nodal sinuses, the mar-ginal sinuses giving the node a clearly definedcontour. Its size varies widely and it maymeasure as much as 3 cm. in its long diameter.Malignant cells enter the node by afferentchannels to reach the marginal sinus wherethey may be arrested and metastases formed.In the early stages, therefore, a metastaticdeposit appears as a peripheral filling defect,usually with an irregular margin. Theaccuracy of lymphography in detecting metas-tases varies with the size of the deposit. Inthe early stages, when a node is not enlargedand is only partially replaced by tumour tissue,an accurate diagnosis cannot be made withconfidence (Kendall, Arthur and Patey, 1963).Similar filling defects may. be produced by avariety of non-malignant conditions. Areas offibrosis or fatty degeneration usually produceclearly defined, central filling defects (Fig. 4,A)but may cause peripheral defects indistinguish-able from metastatic deposits. The hilumnormally appears as a clearly defined impressionat the proximal pole of the node, but onoccasion may show as an ill-defined fillingdefect (Fig. 4,B). As a rule the position ofthe hilum can be identified on the initial filmshowing the contrast filled afferent and efferentvessels, but this is not always so. The marginsof partially superimposed nodes may give anappearance similar to a filling defect (Fig. 4,C).The lymph follicles may produce defects up to3 mm. in diameter. Inguinal and external iliacnodes, in particular, may show incompletefilling due to recurrent inflammatory changes,secondary to repeated lower limb infections(Fig. 4,D). The diagnosis of small metastaticdeposits at this stage is not, therefore, possible.With enlargement of the deposit, however, areaction occurs in the remainder of the noderesulting in an increase in size. Baum, Bron,Wexler and Abrams (1963) suggest that apositive diagnosis can be made if the node isenlarged and the deposit occupies not less than25% of the node. Unfortunately, nodes varyin size to such an extent that it is often difficultto say whether they are enlarged or not, and,in addition, non-malignant conditions mayresult in non-filling of 25% of the node ormore.At a later stage there is complete replace-

ment of the node by malignant tissue. Thenode is then not visualised at all and, since thedistribution of nodes is neither constant nor

FIG. 5.-Lymphogram of patient with right testistumour. There is evidence of lymphatic obstruc-tion at the level of L.V.5, due to a metastaticdeposit. A dilated collateral channel is seen(Arrow).

symmetrical, the lymphographic appearancesmay not be abnormal. At this stage, however,the deposit frequently gives rise to evidence oflymphatic obstruction (Fig. 5). This appearsas irregularity or sudden alteration in the courseof lymph vessels (Fig. 6), retention of contrastwithin the vessels in the 24-hour film, evidenceof dermal backiflow and the presence ofcollateral channels. Dilatation has not beenfound to be a significant feature, since wide,beaded lymphatics are frequently seen in theabsence of obstruction. At this stage, therefore,a diagnosis of metastatic deposit can often bemade by an evaluation of indirect signs, andthe accuracy of diagnosis will largely dependon the experience of the observer. Closescrutiny of the initial films, taken at thetermination of the injection, is essential, sincethese are frequently more helpful than the24-hour films, showing only the nodes (Fig. 6).With further enlargement a metastatic mass

is formed, and at this stage lymphography is ahighly accurate procedure. In addition to theindirect signs of lymphatic obstruction there isfrequently contrast filling of irregular, abnormallymph spaces within the mass (Fig. 7), andoutlining of part of the periphery is a common

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finding (Fig. 12). No normal nodes are demon-strated in the region of the mass. Rarely, Ihave seen a mass containing a fine meshworkof contrast filled channels (FIG. 9A).

It should be appreciated that retroperitonealmetastases, up to the stage when there iscomplete replacement of the node, are rarelydetectable by clinical examination or by otherradiological methods and that lymphographyat least offers a possibility of their recognition,although negative findings have, of course, littlesignificance. In my own experience, lympho-graphy has on a number of occasions demon-strated clinically unsuspected metastases intumours of testis, bladder and cervix, and I donot agree with Koehler, Meyers, Skelley andSchaffer (1964) who consider that lympho-graphy rarely shows deposits which are notsuspected on physical examination. Evenmetastatic masses may reach a surprising sizewithout being clinically palpable, and the sameis true of lymphomatous nodes.The lymphographic appearances in the

reticuloses are characteristic. They produceenlarged lymph nodes with an open, lacy pat-tern and, in the early stages, a very clearlydefined, intact outline. With enlargement ofthe affected nodes the pattern becomes faintand ghost-like and begins to disintegrate. Asa rule the reticuloses are not associated withany evidence of lymphatic obstruction. Onoccasion, Hodgkin's disease may be differen-tiated since, in addition to the above features,the nodes may contain irregular, central fillingdefects. It is said that chronic lymphaticleukemia may be associated with irregular,central pools of contrast, within the backgroundpattern described above. Rarely, seminomametastases may have a similar lacy pattern(Whitesel, 1964), and further possible sources oferror are rheumatoid arthritis and sarcoidosis,both of which may be associated with a diffuselymphadenopathy and a reticular nodal pattern.Nevertheless, lymphography has a high degreeof accuracy in detecting nodes involved by areticulosis.Acute inflammation also gives rise to lymph

node enlargement but the normal internalpattern is usually retained. On occasion, how-ever, peripheral defects may occur giving riseto confusion with metastatic deposits (Fig. 8).

Clinical ApplicationsTestis Tumours

Contrast injections into lymph vessels in thespermatic cord have confirmed Rouviere's(1932) classic description of the lymphatic

FIG. 7.-Right oblique pelvis film of patient withcarcinoma of the cervix. There is contrastfilling of multiple, irregular, abnormal lymphspaces within a metastatic mass.

drainage of the testis. Lymph vessels accom-pany the spermatic vessels and drain into para-aortic nodes from the level of the renal veinsto the bifurcation of the aorta. A further vesseldiverges to reach an external iliac node. Inaddition, tumours which transgress the tunicaalbuginea may metastasise to inguinal nodes.All of these nodes are visualised by lympho-graphy carried out from the foot. Lympho-graphy has also demonstrated that lymphdrainage from a testis is also to the contralateralpara-aortic nodes.

In this country it is almost universal practiceto treat testis tumours by orchidectomyfollowed by supervoltage radiotherapy to thepara-aortic nodes and to pelvic nodes on theside of the tumour (Smithers and Wallace,1962). Results with this technique have beenexcellent for seminomas but not quite so goodfor teratomas. Elsewhere, retroperitoneallymphadenectomy, usually with subsequentradiotherapy, has been favoured by many forteratomas (Tavel, Osius, Parker, Goodfriend,McGonigle, Jassie, Simmons, Tobenkin andSchulte, 1963) and by some for all tumours.There is little doubt that radical surgery isunnecessary for seminomas and for the major-ity of tera'tomas, but it has probably a placein the management of those teratomas whichare relatively radioresistant. Whichever formof treatment is preferred lymphography is of

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460 POSTGRADUATE MEDICAL JOURNAL August, 1965

FIG. 8.-Enlarged superficial inguinal lymph nodesdue to an acute inflammatory reaction. Irregularfilling defects are shown in the absence ofmetastatic deposits.

considerable value. To the radiotherapist itoffers a means of reducing to a minimum thevolume of tissue irradiated while at the sametime ensuring that all relevant lymph nodesare -treated. Such restriction of the size ofthe field is essential, even with supervoltageradiotherapy, to avoid damage to other tissues,particularly the kidneys. When a nodal meta-stasis or metastatic mass is demonstratedaddiltional, strictly localised radiation may bedelivered to it. Delineation of the outline of amass is, therefore, of great importance and itmuSt be admitted that in this respect lympho-graphy may be disappointing. It will showthe presence and site of the lesion but willfrequently fail to demonstralte its exact extent.In the right para-aortic region cavography maygive valuable information regarding the sizeof a mass, partticularly if it arises from retro-caval nodes, although left-sided lesions mayreach a very large size without producing anyeffect whatever on 'the vena cava (Mahaffy,1964) (Fig. 9). In addition, urography may

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help in demonstrating the lateral extent of amass by showing displacement of -the ureter.In such cases, therefore, these three proceduresare complementary and all should be carriedout (Fig. 10). Contrast remains within the lymphnodes for several months following lympho-graphy and the response of a mass to radio-therapy can, therefore, be assessed fromsubsequent plain films (Fig. 11). A furtheradvan-tage of lymphography is that it may in-dicate the necessity for mediastinal and supra-clavicular therapy, which would not otherwisehave been given, by demonstrating clinicallyunsuspected para-aortic metastases.

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August, 1965 MAHAFFY: Lymphoeraphy and the Urologist 461

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Where radical surgery has been preferredlymphography has proved to be of great valueas an aid to total extirpation of retroperitonealnodes. One of the arguments againsit lymph-adenectomy has been the impossibility ofachieving complete removal of all nodes, theretrocaval and renal regions being the mostdifficult to dissect. Even in cadavers, Tavel andhis associates (1963) failed to remove all para-aortic nodes. Following lymphography, how-ever, with the aid of image intensification orradiography in the operating theatre, total

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FIG. 9.-Right testis tumour. The lymphogram (A)shows a large, rounded metastatic mass at thelevel of L.V.4 (Arrows), containing a fine mesh-work of lymphatic channels. Above this thereare multiple, irregular, contrast filled spaces withno normal nodes seen, indicating a further mass.A cavogram (B and C) shows the lower massto lie anterior to the vena cava and to producelittle impression on the vein. The upper masslies posteriorly and produces very marked dis-placement. The cavogram gives a much moreaccurate estimate of the extent of the posteriormass than does the lymphogram.

lymphadenectomy is now possible. Theaddition of chlorophyll to lipiodol is also ofassistance to the surgeon, since by this methodthe nodes are coloured green and are readilyvisible, alithough there is a tendency for thenodes closer to the site of injection to takeup more dye than those more distal. Wheresurgical treatment is indicated lymphography

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FIG. IOA FIG. lOB

FIG. 1O.-Right testis tumour. The cavogram (A and B) shows a large mass anterior and tothe right of the inferior vena zava. The lymphogram (C and D) shows evidence oflymphatic obstruction at the level of L.V.5, with filling of very few right para-aortic nodesabove this, indicating the presence of a metastatic mass but giving no idea of its extent.The urogram i(C and D) shows displacement of the ureter, indicating the lateral extentof the mass. In this case all three procedures contributed to an accurate assessment ofthe lesion.

has clearly demonstrated the necessity for bi-lateral lymphadenectomy.Macdonald and Wallace (1965) describe a

further application of lymphography to testistumours. In patients who present with supra-clavicular node metastases from a seminoma orteratoma, with clinically normal testes, alymphogram may demonstrate para-aortic nodedeposits, indicating that the primary is, in fact,testicular and not mediastinal.

Renal TumoursLymphatic drainage from the kidneys is

largely to the para-aortic nodes at the level ofthe hilum, although the posterior aspect of theupper pole may drain through the diaphragmto the lower posterior mediastinal nodes.Metastases iin the para-aortic nodes are notuncommon and may be demonstrated bylymphography. Robson (1963) reported a 22.5%incidence of regional node metastases in renalcell carcinoma. He advocates a radical neph-rectomy, which includes block dissection ofpara-aortic nodes, and with this techniqueclaims to have improved survival figures. Forthe best results. however. such dissection would

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August, 1965 MAHAFFY: Lymphography and the Urologist 463

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have to be bilateral. Lymphography may aidin selection of patients for radical operationand will assist in achieving complete lymph-adenectomy.

Bladder TumoursThe lymphatic drainage of the bladder is in

three directions; from the superior and infero-lateral surfaces to the external iliac nodes(Fig. 12); from -the base largely to the externaliliac but also to the internal iliac inodes; fromthe neck to the internal and common iliacnodes (Fig. 13). It is one of the disadvantagesof lymphography carried out from the foot thatthe internal iliac chain is not demonstrated inits entirety, although several of these nodesare frequently seen. Radiological deteotion ofinternal iliac metastases may be achieved insome cases by urography (Fig. 14) or pelvicvenography, although the sensitivity of theseprocedures is not high. However, the internal

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iliac chain is of relatively minor importance inthe lymphatic drainage of pelvic organs (Her-man and others, 1963).The choice of treatment for each stage and

grade of bladder tumour is largely a matter ofpersonal preference. Uniformly good resultsare obtained with early stage and low-gradetumours but the wide variety of techniquesadvocated for invasive tumours reflects thepoor results obtained in these cases. Whitmoreand Marshall (1962) use radical cystectomy as acurative procedure and include pelvic lympha-denectomy from the mid-common-iliac regionto the inguinal ligament. The lymphographicdetection of more than two metastases rules outthe possibility of cure in their opinion andpalliative treatment only is given. Again,lymphography will assist the surgeon duringpelvic node dissection and will also contributeinformation of value in accurately stagingtumours and, therefore, in assessing theeffectiveness of treatment.

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AFIG. 11.-Left testis tumour. The lymphogram shows an extensive left para-aortic .metastatic

mass (A). Three months Ifollowing radiotherapy much of the contrast medium hasdisappeared but the extent of the mass is unaltered l(B).

Prostatic TumoursThe importance of lymphatic metastases from

carcinoma of the prostate has tended to beunderestimated in the past. An appreciablenumber of such patients have lymph nodedeposits, which are clinically undetectable, ata time when no bony deposits are present.Flocks (1963) found nodal metastases in 40%of patients with extraprostatic extension of thetumour and in 8% of those without such ex-tension. The commonest sites of such depositsare the internal iliac, obturator and commoniliac nodes, but metastases may also occur inpara-aor,tic and tracheobronchial nodes.Lymphatic metastases are not responsive tohormone therapy and, therefore, must betreated by other means. Flocks advises radical

prostatectomy wilth pelvic node dissection inall cases considered operable, and lympho-graphy is of obvious value in such a procedure.

Penile TumoursThe lymph drainage of the penis is to the

superficial and deep inguinal nodes and to theiliac chains. The usual treatment of peniletumours is amputation of the penis with blockdissection of the inguinal, obturator and iliacnodes in those cases where metastases are pre-sent (Buddington, Kickham and Smith, 1963).Lymphography may demonstrate deposits inclinically impalpable nodes and, conversely,may show that palpably enlarged inodes areinflammatory and not neoplastic. It may, there-fore, give information of value in deciding

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FIG. 12.-Bladder tumour. The lymphogram showsa left external iliac node with a peripheral fillingdefect and partial outlining of the periphery of ametastatic deposit (Arrows).

whether block dissection is necessary or not andwill provide radiographic control of theprocedure if dissection is carried out.

Intralymphatic RadiotherapyThe advantages of intralymphatic radio-

therapy using 1311 lipiodol are still being assessed(Seitzman, Wright, Halaby and Freeman, 1963).Zeidman, Copeland and Warren (1955) haveshown that there is no circulation of lymphthrough a 'metastatic deposit in a node. Since1311 produces shortly penetrating 'beta radiationit must come into intimate contact with theindividual malignant cells in order to be effect-ive. It will be of value, therefore, againstsolitary, viable malignant cells and possiblyto some extent against microscopic deposits,but will have little effect against establishedmetastases. When injected at the foot externalscanning methods have demonstrated that it isretained in the inguinal, pelvic, para-aortic andleft supraclavicular nodes. Since the lipiodolis filtered off in the lungs there is a dan-ger thatthese organs will receive a signtificant amountof radiation. Seitzman and his colleagues(1963) have claimed that by stopping the in-jection when the contrast reaches the thoracicduct, or if any evidence of lymphatic obstruc-tion is seen, this danger can be avoided, andthat there is no measurable uptake by ithe liver,

spleen, kidneys or thyroid. No sys;temic re-action is produced and there is no effect onhemopoiesis. On the other hand, Koehlerand his associates ,(1964) found, in experimentson dogs, that as much as 50% of the radioactivematerial was deposited in the lungs and thatif the amount injected was reduced to avoidthis, insufficient radiation was given to thenodes. It would seem that further work isnecessary to assess accurately the risk ofpulmonary damage in this technique. Never-theless, it is an effective method of deliveringradiotherapy to the lymphatic system. T-hereis virtually no irradiation of tissues surround-ing the nodes and general reactions do notoccur. It would seem logical to use this tech-nique in tumours of testis, penis, prostate,bladder and kidney prior to lymphadenectomyto avoid the dissemination of viable malignantcells during the operative procedure, and alsoso that any lymphatic tissue left behind willcontain no such cells. It may be used inaddition to external radiotherapy withoutincreasing the dosage to surrounding tissues orthe extent of any general reaction. The dosageto a node will be proportional to its uptakeof contrast and the amount of radiation receivedby any node can, therefore, be assessed fromplain films. Gough, Guiney and Kinmonth(1963) have reported encouraging results withintralymphatic 138Au in the treatment ofmelanomata in which there was no clinicalevidence of lymph node metastases. In thereticuloses lymph continues to circulate throughthe affected nodes, at any rate in the earlystages, and, as would be expected, this techniquehas proved to be of considerable value(Chiappa, Galli and Severini, 1964).

ChyluriaChyluria occurs as a result of an abnormal

communication between the urinary and lym-phatic systems. Such a communication isprobably due to rupture of a lymphatic varixinto the pelvis or calyces, the varix beingformed as a result of chronic increased intra-lymphatic pressure. In the majority of caseschyluria is associated with filariasis and inareas in which this infestation is endemic thediagnosis presents little difficulty. Elsewhere,however, other causes must be excluded, suchas thoracic duct obstruction from tumour ortrauma, or congenital valvular incompetenceof the lymphatics. Retrograde pyelographyalmost always shows pyelolymphatic reflux.On lymphography characteristic changes aredemonstrated. The para-aortic lymphatics are

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August, 1965 MAHAFFY: Lymphography and the Urologist 467

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FIG. 14.-Carcinoma of the cervix. A lymphogramshowed no ah-urmality. Urogr-;w showsmedial displacement of the left ureter by aninternal iliac metastasis.

ectatic and tortuous, and multiple, abnormalvessels are seen passing from the lumbar chainto the kidneys. These vessels, which are seenonly in chyluria, frequently reach the calyces,into which the lipiodol may pass, giving riseto a pyelogram. In the 24-hour film few nodesare seen as a rule in the para-aortic region andthose present frequently contain filling defects(Kishimoto, Higuchi, Endo and Kai, 1964).These appearances are in keeping with the workof Yamauchi (1945), who described cicatricialchanges in the nodes and loss of elasticity inthe lymph vessels in cases of chyluria (Swanson,1963).Treatment of this condition has in the past

been unsatisfactory. Bed rest, by reducing theintralymphatic pressure, has produced tem-porary remissions, and chyluria can always bereduced by restriction of dietary fats. Theinstillation of sclerosing agents, such as silvernitrate or sodium iodide, into the renal pelvisseldom gives lasting benefit. Recently, however,excision of all lymphatic structures in the renalpedicle has proved a highly successful methodof treatment, and in such a procedure onewould expect lymphography to be of value indemonstrating the number and position ofthose vessels whose interruption is necessary.It can also be carried out following surgery to

FIG. 15.-This patient presented with a left iliacfossa mass, of unknown aetiology. Barium enemaand urography were negative. The lymphogramshows scanty contrast filling of a left pelvicmass with, elsewhere, nodal changes typical ofHodgkin's disease.

show the completeness of the operation.Cockett and Goodwin (1962) treated a case byanastomosis of a large lymphatic to the sper-matic vein but the effect of this procedurecould not be assessed since the remainder ofthe abnormal -lymphatics were excised and asuccessful outcome may have been due to this.

Retroperitoneal FibrosisClouse, Fraley and Litwin (1964) have

reported on the lymphographic appearances inthree cases of retroperitoneal fibrosis. Theyfound non-filling of lymph vessels above thelevel of the 4th lumbar vertebra, stasis anddilatation of vessels below this, and extensivefilling of hypogastric, presacral and peritonealcollaterals. They claim that a diagnosis canbe made lymphographically before thecharacteristic ureteric abnormalities can bedetected by urography or retrograde pyelo-graphy. These lymphographic appearances arenot specific for retroperitoneal fibrosis butshould raise the suspicion of this condition.

Abdominal or Pelvic MassesLymphography may be of value in the

investigation of abdominal or pelvic masses ofunknown aetiology. These may produce dis-placement or obstruction of a ureter or kidney,possibly with resulting hydronephrosis. It willdetermine whether such a mass is lymphatic in

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orign and in many cases will indicate thenature of the pathology (Fig. 15). Carcinomatousmetastases and reticuloses may present in thisway.

Figures 6 and 9 are reproduced by permission ofthe British Journal of Radiology, figures 1B, 5 and12 by permission of the Journal of the Royal Collegeof Surgeons of Edinburgh.

REFERENCESBAUM, S., BRON, K., WEXLER, L., and ABRANiS, H.

i(1963): Lymnphangiography, Cavography andUrography, Radiology, 81, 207.

BENNET, H., and SHIVAS, A. (1954): The Visualisationof Lymph Nodes and Vessels by Ethyl Iodos-tearate (Angiopac) and its Effect on LymphoidTissue, J. Fac. Radiol. (Lond.), 5, 261.

BRON, K., BAUM, S., and ABRAMS, H. (1963): OilEmbolism in Lymphangiography, Radiology, 80,194.

BRuuN, S., and ENGESET, A. (1956): Lymphadeno-graphy: A New Method for the Visualisation ofEnlarged Lymph Nodes and Lymphatic Vessels,Acta radiol. (Stockh.), 45, 389.

BUDDINGTON, W., KICKHAM, C., and SMITH, W.(1963): An Assessment of Malignant Disease of thePeenis, J. Urol. (Baltimore), 89, 442.

CHIAPPA, .S., GALLI, G., and SEVERINI, A. (1964):Lymphadenography with Radioactive ContrastMedium in Retroperitoneal Localisation of Malig-nant Lyniphogranuloma, Amer. J. Roentgenol., 92,134.

CLOUSE, M., FRALEY, E., and LITWIN, S. (1964):Lymphangiographic Criteria for Diagnosis ofRetroperitoneal Fibrosis, Radiology, 83, 1.

CQCKETr; A., and GOODWIN, W. (1962): Chyluria:Attempted Surgical Treatment. by Lymphatic-Venous Anastomosis, J. Urol. (Baltimore), 88, 566.

DESPREZ-CURELY, J., BisMuTH, V., LAUGIER, A., andDESCAMPS, J. (1962): Accidents and Complicationsof Lymphography, Ann. Radiol., 7-8, 577.

FLOcKs, R. (1963): Combination Therapy forLocalised Prostatic Cancer, J. Urol. (Baltimore),89, 889.

GOUGH, M., GUINEY, E., and KINMONTH, J. (1963):Lymphangiography: New Techniques and Uses,

,Bffrit. -med. J., i; 1181..HERMAN, P., BENNINGHOFF, D., NELSON, J., and

MELLINS, H. (1963): Roentgen Anatomy of theIlio-Pelvic-Aortic Lymphatic System, Radiology,80, 182.

JACOBSSON, S., and JOHANSSON, S. (1959): NormalRoentgen Anatomy of the Lymph Vessels ofUpper and Lower Exremities, Acta radiol. (Stockh.),51, 321.

KENDALL, B., ARTHUR, J., and PATEY, D. (1963):Lymphangiography in Carcinoma of the Breast,Cancer. 16, 1233.

KINMONTH, J. B. ,(1952): Lymphangiography in Man:Method of Outlining Trunks at Operation, Clin.Sci., 11, 13.

KISHIMOTO, T., HIGUCHI, T., ENDo, M., and KAI, Y.(1964): Lymphography in a Patient with UnilateralChyluria, J. Urol. (Baltimore), 92, 574.

KOEHLER, P., MEYERS, W., SKELLEY, J., and SCHAFFER,B. (1964): Body Distribution of Ethiodol FollowingLymphangiography, Radiology, 82, 866.

MACDONALD, J., and WALLACE, E. (1965): Lymphan-giography in Tumours of Kidney, Bladder andTesticle, Brit. J. Radiol., 38, 93.

MAHAFFY, R. (1964): A Comparison of the Diag-nostic Accuracy of Lymphography, Cavographyand Pelvic Venography, Brit. J. Radiol., 37, 422.

MENVLLE, L., and ANE, J. (1932): Roentgen Visuali-sation of Lymph Nodes in Animals, J. Amer. med.Ass., 98, 1796.

ROBSON, C. (1963): Radical Nephrectomy for RenalCell Carcinoma, J. Urol. ,(Baltimore), 89, 37.

ROUVIERE, H. (1932): Anatomie des Lymphatiquesde l'Homme, Paris: Masson et Cie.

RUTrIMANN, A., and DEL BUONO, M. (1962):Lymphography with Oily Contrast Medium.Technique and Preliminary Results, Fortschr.Rontgenstr., 97, 551.

SEITZMAN, D., WRIGHT, R., HALABY, F., and FREEMAN,J. (1963): Radioactive Lymphangiography as aTherapeutic Adjunct, Amer. J. Roentgenol., 89, 140.

SEITZMAN, D., and HALABY, F. (1964): Lymphangio-graphy: An Evaluation, J. Urol. (Baltimore), 91,301.

SMITHERS, D., and WALLACE, E. (1962): Radiotherapyin the Treatment of Patients with Seminomas andTeratomas of the Testicle, Brit. J. Urol., 34, 422.

SWANSON, G. (1963): Lymphangiography in Chyluria,Radiology, 81, 473.

TAVEL, F., Osius, T., PARKER, J., GOODFRIEND, R.,McGoNIGLE, D., JASSIE, M., SIMMONS, E.,TOBENKIN, M., and SCHULTE, J. (1963): Retroperi-toneal Lymph Node Dissection, J. Urol. (Baltimore),89, 241.

WALLACE, S., JACKSON, L., SCHAFFER, B., GOULD, J.,GREENING, R., WEISS, A., and KRAMER, S. (1961):Lymphangiograms: Their Diagnostic and Thera-peutic Potential, Radiology, 76, 179.

WHITESEL, J. (1964): Lymphography: Its Place inUrology, J. Urol. (Baltimore), 91, 613.

WHITMORE, W., and MARSHALL, V. (1962): RadicalTotal Cystectomy for Cancer of the Bladder: 230Consecutive Cases 5 Years Later, J. Urol.(Baltimore), 87, 853.

YAMAUCHI, S. (1945): Chyluria; Clinical, Laboratoryand Statistical Study of 45 Personal Cases Observedin Hawaii, J. Urol. (Baltimore), 54, 318.

ZEIDMAN, I., COPELAND, B., and WARREN, S. (1955):Experimental Studies on Spread of Cancer inLymphatic System; Absence of Lymphatic Supplyin Carcinoma, Cancer, 8, 123.

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